Horizon NJ Health Pre-Authorization Codes Managed by eviCore
Tikka Attach
Horizon NJ Medicaid and FIDE-SNP
Radiology and Cardiology Code list
Code Code Description
33214
Upgrade of implanted pacemaker system, conversion of single
chamber system to dual chamber system (includes removal of
previously placed pulse generator, testing of existing lead,
insertion of new lead, insertion of new generator)
33221
Insertion of pacemaker pulse generator only; with existing
multiple leads
33224
Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, with attachment to previously placed
pacemaker or pacing cardioverter-defibrillator pulse generator
(including revision of pocket, removal, insertion, and/or
replacement of existing generator)
33225
Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, at time of insertion of pacing cardioverter-
defibrillator or pacemaker pulse generator (including upgrade
to dual chamber system and pocket revision) (list separately in
addition to code for primary procedure)
33227
Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; single lead system
33228
Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; dual lead system
33229
Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; multiple lead
system
33230
Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing dual leads
33231
Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing multiple leads
33240
Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing single lead
33249
Insertion or replacement of permanent pacing cardioverter-
defibrillator system with transvenous lead(s), single or dual
chamber
33262
Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; single lead system
33263
Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; dual lead system
Code Code Description
33264
Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; multiple lead system
33270
Insertion or replacement of permanent subcutaneous
implantable defibrillator system, with subcutaneous electrode,
including defibrillation
threshold evaluation, induction of arrhythmia, evaluation of
sensing for
arrhythmia termination, and programming or reprogramming
of sensing
or therapeutic parameters, when performed
72275 Epidurography, radiological supervision and interpretation
72285
Discography, cervical or thoracic, radiological supervision and
interpretation
72295
Discography, lumbar, radiological supervision and
interpretation
74261
Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; without contrast material
74262
Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; with contrast material(s)
including non-contrast images, if performed
74263
Computed tomographic (CT) colonography, screening,
including image postprocessing
78499
Unlisted cardiovascular procedure, diagnostic nuclear medicine
78699
Unlisted nervous system procedure, diagnostic nuclear
medicine
78999
Unlisted miscellaneous procedure, diagnostic nuclear medicine
0042T
Cerebral perfusion analysis using computed tomography with
contrast administration, including post-processing of
parametric maps with determination of cerebral blood flow,
cerebral blood volume, and mean transit time
0501T
Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software
analysis of functional data to assess the severity of coronary
artery disease; data preparation and transmission, analysis of
fluid dynamics and simulated maximal coronary hyperemia,
generation of estimated FFR model, with anatomical data
review in comparison with estimated FFR model to reconcile
discordant data, interpretation and report
Code Code Description
0502T
Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; data preparation and transmission
0503T
Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; analysis of fluid dynamics and
simulated maximal coronary hyperemia, and generation of
estimated FFR model
0504T
Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; anatomical data review in comparison
with estimated FFR model to reconcile discordant data,
interpretation and report
C8921
Transthoracic echocardiography with contrast for congenital
cardiac anomalies; complete
C8922
Transthoracic echocardiography with contrast for congenital
cardiac anomalies; follow-up or limited study
C8923
Transthoracic echocardiography with contrast, real-time with
image documentation (2d) with or without m-mode
recording;complete
C8924
Transthoracic echocardiography with contrast, real-time with
image documentation (2d) with or without m-mode recording;
follow-up or limited study
C8925
Transeophageal echocardiography (tee) with contrast, real
time with image documentation (2d) (with or without m-mode
recording); including probe placement, image acquistion,
interpretation and report
C8926
Transeophageal echocardiography (tee) with contrast for
congenital cardiac anomalies; including probe placement,
image acquistion, interpretation and report
C8928
Transthoracic echocardiography with contrast, real-time with
image documentation (2d), with or without m-mode recording,
during rest and cariovascular stress test using treadmill, bicycle
exercise and/or pharmacologically induced stress, with
interpretati
Code Code Description
C8929
Transthoracic echocardiography, with contrast, or without
contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when
performed, complete, with spectral doppler echocardiography,
and with color flow doppler
C8930
Transthoracic echocardiography, with contrast, or without
contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise
G0297 Low dose cancer screening
70336
Magnetic resonance (eg, proton) imaging, temporomandibular
joint(s)
70450
Computed tomography, head or brain; without contrast
material
70460
Computed tomography, head or brain; with contrast
material(s)
70470
Computed tomography, head or brain; without contrast
material, followed by contrast material(s) and further sections
70480
Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; without contrast material
70481
Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; with contrast material(s)
70482
Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; without contrast material, followed by
contrast material(s) and further sections
70486
Computed tomography, maxillofacial area; without contrast
material
70487
Computed tomography, maxillofacial area; with contrast
material(s)
70488
Computed tomography, maxillofacial area; without contrast
material, followed by contrast material(s) and further sections
70490
Computed tomography, soft tissue neck; without contrast
material
70491
Computed tomography, soft tissue neck; with contrast
material(s)
70492
Computed tomography, soft tissue neck; without contrast
material followed by contrast material(s) and further sections
70496
Computed tomographic angiography, head, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing
Code Code Description
70498
Computed tomographic angiography, neck, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing
70540
Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s)
70542
Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; with contrast material(s)
70543
Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s), followed by contrast
material(s) and further sequences
70544
Magnetic resonance angiography, head; without contrast
material(s)
70545
Magnetic resonance angiography, head; with contrast
material(s)
70546
Magnetic resonance angiography, head; without contrast
material(s), followed by contrast material(s) and further
sequences
70547
Magnetic resonance angiography, neck; without contrast
material(s)
70548
Magnetic resonance angiography, neck; with contrast
material(s)
70549
Magnetic resonance angiography, neck; without contrast
material(s), followed by contrast material(s) and further
sequences
70551
Magnetic resonance (eg, proton) imaging, brain (including
brain stem); without contrast material
70552
Magnetic resonance (eg, proton) imaging, brain (including
brain stem); with contrast material(s)
70553
Magnetic resonance (eg, proton) imaging, brain (including
brain stem); without contrast material, followed by contrast
material(s) and further sequences
70554
Magnetic resonance imaging, brain, functional MRI; including
test selection and administration of repetitive body part
movement and/or visual stimulation, not requiring physician or
psychologist administration
70555
Magnetic resonance imaging, brain, functional MRI; requiring
physician or psychologist administration of entire
neurofunctional testing
71250 Computed tomography, thorax; without contrast material
71260 Computed tomography, thorax; with contrast material(s)
71270
Computed tomography, thorax; without contrast material,
followed by contrast material(s) and further sections
71275
Computed tomographic angiography, chest (noncoronary),
with contrast material(s), including noncontrast images, if
performed, and image postprocessing
Code Code Description
71550
Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s)
71551
Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); with
contrast material(s)
71552
Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s), followed by contrast material(s) and
further sequences
71555
Magnetic resonance angiography, chest (excluding
myocardium), with or without contrast material(s)
72125
Computed tomography, cervical spine; without contrast
material
72126
Computed tomography, cervical spine; with contrast material
72127
Computed tomography, cervical spine; without contrast
material, followed by contrast material(s) and further sections
72128
Computed tomography, thoracic spine; without contrast
material
72129
Computed tomography, thoracic spine; with contrast material
72130
Computed tomography, thoracic spine; without contrast
material, followed by contrast material(s) and further sections
72131
Computed tomography, lumbar spine; without contrast
material
72132 Computed tomography, lumbar spine; with contrast material
72133
Computed tomography, lumbar spine; without contrast
material, followed by contrast material(s) and further sections
72141
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; without contrast material
72142
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; with contrast material(s)
72146
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, thoracic; without contrast material
72147
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, thoracic; with contrast material(s)
72148
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; without contrast material
72149
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; with contrast material(s)
Code Code Description
72156
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; cervical
72157
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; thoracic
72158
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; lumbar
72159
Magnetic resonance angiography, spinal canal and contents,
with or without contrast material(s)
72191
Computed tomographic angiography, pelvis, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing
72192 Computed tomography, pelvis; without contrast material
72193 Computed tomography, pelvis; with contrast material(s)
72194
Computed tomography, pelvis; without contrast material,
followed by contrast material(s) and further sections
72195
Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s)
72196
Magnetic resonance (eg, proton) imaging, pelvis; with contrast
material(s)
72197
Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s), followed by contrast material(s) and
further sequences
72198
Magnetic resonance angiography, pelvis, with or without
contrast material(s)
73200
Computed tomography, upper extremity; without contrast
material
73201
Computed tomography, upper extremity; with contrast
material(s)
73202
Computed tomography, upper extremity; without contrast
material, followed by contrast material(s) and further sections
73206
Computed tomographic angiography, upper extremity, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing
73218
Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; without contrast material(s)
73219
Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; with contrast material(s)
73220
Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences
73221
Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; without contrast material(s)
Code Code Description
73222
Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; with contrast material(s)
73223
Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; without contrast material(s), followed by contrast
material(s) and further sequences
73225
Magnetic resonance angiography, upper extremity, with or
without contrast material(s)
73700
Computed tomography, lower extremity; without contrast
material
73701
Computed tomography, lower extremity; with contrast
material(s)
73702
Computed tomography, lower extremity; without contrast
material, followed by contrast material(s) and further sections
73706
Computed tomographic angiography, lower extremity, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing
73718
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s)
73719
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; with contrast material(s)
73720
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences
73721
Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material
73722
Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; with contrast material(s)
73723
Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material(s), followed by contrast
material(s) and further sequences
73725
Magnetic resonance angiography, lower extremity, with or
without contrast material(s)
74150
Computed tomography, abdomen; without contrast material
74160 Computed tomography, abdomen; with contrast material(s)
74170
Computed tomography, abdomen; without contrast material,
followed by contrast material(s) and further sections
74174
Computed tomographic angiography, abdomen and pelvis,
with contrast material(s), including noncontrast images, if
performed, and image postprocessing
74175
Computed tomographic angiography, abdomen, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing
Code Code Description
74176
Computed Tomography, Abdomen And Pelvis; Without
Contrast Material
74177
Computed Tomography, Abdomen And Pelvis; With Contrast
Material(S)
74178
Computed Tomography, Abdomen And Pelvis; Without
Contrast Material In One Or Both Body Regions, Followed By
Contrast Material(S) And Further Sections In One Or Both Body
Regions
74181
Magnetic resonance (eg, proton) imaging, abdomen; without
contrast material(s)
74182
Magnetic resonance (eg, proton) imaging, abdomen; with
contrast material(s)
74183
Magnetic resonance (eg, proton) imaging, abdomen; without
contrast material(s), followed by with contrast material(s) and
further sequences
74185
Magnetic resonance angiography, abdomen, with or without
contrast material(s)
74712 MRI Fetal single/first gestation
74713 MRI Fetal each additional gestation
75557
Cardiac magnetic resonance imaging for morphology and
function without contrast material;
75559
Cardiac magnetic resonance imaging for morphology and
function without contrast material; with stress imaging
75561
Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences;
75563
Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences; with stress imaging
75571
COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST
MATERIAL, WITH QUANTITIVE EVALUATION OF CORONARY
CALCIUM
75572 CARDIAC CT FOR MORPHOLOGY
75573 CARDIAC CT FOR CONGENITAL HD
75574 CORONARY CTA
75635
Computed tomographic angiography, abdominal aorta and
bilateral iliofemoral lower extremity runoff, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing
76376
3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; not requiring image
postprocessing on an independent workstation
Code Code Description
76377
3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; requiring image postprocessing
on an independent workstation
76380 Computed tomography, limited or localized follow-up study
76390 Magnetic resonance spectroscopy
76391 Magnetic resonance (eg, vibration) elastography
76497
Unlisted computed tomography procedure (eg, diagnostic,
interventional)
76498
Unlisted magnetic resonance procedure (eg, diagnostic,
interventional)
77021
Magnetic resonance imaging guidance for needle placement
(eg, for biopsy, needle aspiration, injection, or placement of
localization device) radiological supervision and interpretation
77022
Magnetic resonance imaging guidance for, and monitoring of,
parenchymal tissue ablation
77046
Magnetic resonance imaging, breast, without contrast
material; unilateral
77047
Magnetic resonance imaging, breast, without contrast
material; bilateral
77048
Magnetic resonance imaging, breast, without and with contrast
material(s),
including computer-aided detection (CAD real-time lesion
detection,
characterization and pharmacokinetic analysis), when
performed; unilateral
77049
Magnetic resonance imaging, breast, without and with contrast
material(s),
including computer-aided detection (CAD real-time lesion
detection,
characterization and pharmacokinetic analysis), when
performed; bilateral
77078
Computed tomography, bone mineral density study, 1 or more
sites; axial skeleton (eg, hips, pelvis, spine)
77084
Magnetic resonance (eg, proton) imaging, bone marrow blood
supply
78012
THYROID UPTAKE, SINGLE RO MULTIPLEQUANTITATIVE
MEASUREMENT(S) (INCLUDING
STIMULATION,SUPPRESSION,OR DISCHARGE, WHEN
PERFORMED)
78013
THYROID IMAGING, (INCLUDING VASCULAR FLOW,WHEN
PERFORMED)
Code Code Description
78014
THYROID IMAGING, (INCLUDING VASCULAR FLOW,WHEN
PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S)
QUANTITATIVE MEASUREMENT(S) (INCLUDING
STIMULATION,SUPPRESSION, OR DISCHARGE, WHEN
PERFORMED)
78015
Thyroid carcinoma metastases imaging; limited area (eg, neck
and chest only)
78016
Thyroid carcinoma metastases imaging; with additional studies
(eg, urinary recovery)
78018 Thyroid carcinoma metastases imaging; whole body
78020
Thyroid carcinoma metastases uptake (List separately in
addition to code for primary procedure)
78070 Parathyroid imaging
78071
PARATHYROID PLANAR IMAGING (INCLUDING
SEBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC
(SPECT)
78072
PARATHYROID PLANAR IMAGING (INCLUDING
SEBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC
(SPECT), AND CONCURRENTLY ACQUIRED
COMPUTEDTOMOGRPAHY (CT) FOR ANATOMICAL
LOCALIZATION.
78075 Adrenal imaging, cortex and/or medulla
78102 Bone marrow imaging; limited area
78103 Bone marrow imaging; multiple areas
78104 Bone marrow imaging; whole body
78185 Spleen imaging only, with or without vascular flow
78195 Lymphatics and lymph nodes imaging
78201 Liver imaging; static only
78202 Liver imaging; with vascular flow
78215 Liver and spleen imaging; static only
78216 Liver and spleen imaging; with vascular flow
78226
Hepatobiliary system imaging, including gallbladder when
present;
78227
Hepatobiliary system imaging, including gallbladder when
present; with pharmacologic intervention, including
quantitative measurement(s) when performed
78230 Salivary gland imaging;
78231 Salivary gland imaging; with serial images
78232 Salivary gland function study
78258 Esophageal motility
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264 Gastric emptying imaging study (eg, solid, liquid, or both)
78265 Gastric emptying imaging study
Code Code Description
78266 Gastric emptying imaging study
78278 Acute gastrointestinal blood loss imaging
78290
Intestine imaging (eg, ectopic gastric mucosa, Meckel's
localization, volvulus)
78291
Peritoneal-venous shunt patency test (eg, for LeVeen, Denver
shunt)
78300 Bone and/or joint imaging; limited area
78305 Bone and/or joint imaging; multiple areas
78306 Bone and/or joint imaging; whole body
78315 Bone and/or joint imaging; three phase study
78429 Myocardial imaging, positron emission tomography (PET),
metabolic evaluation study (including ventricular wall motion[s]
and/or ejection fraction[s], when performed), single study; with
concurrently acquired computed tomography transmission scan
78430 Myocardial imaging, positron emission tomography (PET),
perfusion study (including ventricular wall motion[s] and/or
ejection fraction[s], when performed); single study, at rest or
stress (exercise or pharmacologic), with concurrently acquired
computed tomography transmission scan
78431 Myocardial imaging, positron emission tomography (PET),
perfusion study (including ventricular wall motion[s] and/or
ejection fraction[s], when performed); multiple studies at rest
and stress (exercise or pharmacologic), with concurrently
acquired computed tomography transmission scan
78432 Myocardial imaging, positron emission tomography (PET),
combined perfusion with metabolic evaluation study (including
ventricular wall motion[s] and/or ejection fraction[s], when
performed), dual radiotracer (eg, myocardial viability);
78433 Myocardial imaging, positron emission tomography (PET),
combined perfusion with metabolic evaluation study (including
ventricular wall motion[s] and/or ejection fraction[s], when
performed), dual radiotracer (eg, myocardial viability); with
concurrently acquired computed tomography transmission scan
78434 Absolute quantitation of myocardial blood flow (AQMBF),
positron emission tomography (PET), rest and pharmacologic
stress (List separately in addition to code for primary
procedure)
78414
Determination of central c-v hemodynamics (non-imaging) (eg,
ejection fraction with probe technique) with or without
pharmacologic intervention or exercise, single or multiple
determinations
78428 Cardiac shunt detection
78445
Non-cardiac vascular flow imaging (ie, angiography,
venography)
78451 MPI, SPECT, SINGLE REST OR STRESS
78452 MPI, SPECT, MULTIPLE, REST OR STRESS
78453 MPI, PLANAR, SINGLE REST OR STRESS
78454 MPI, PLANAR, MULTIPLE, REST OR STRESS
78456 Acute venous thrombosis imaging, peptide
78457 Venous thrombosis imaging, venogram; unilateral
78458 Venous thrombosis imaging, venogram; bilateral
78459
Myocardial imaging, positron emission tomography (PET),
metabolic evaluation study (including ventricular wall
motion[s] and/or ejection fraction[s], when performed), single
study
78466
Myocardial imaging, infarct avid, planar; qualitative or
quantitative
78468
Myocardial imaging, infarct avid, planar; with ejection fraction
by first pass technique
78469
Myocardial imaging, infarct avid, planar; tomographic SPECT
with or without quantification
78472
Cardiac blood pool imaging, gated equilibrium; planar, single
study at rest or stress (exercise and/or pharmacologic), wall
motion study plus ejection fraction, with or without additional
quantitative processing
78473
Cardiac blood pool imaging, gated equilibrium; multiple
studies, wall motion study plus ejection fraction, at rest and
stress (exercise and/or pharmacologic), with or without
additional quantification
78481
Cardiac blood pool imaging, (planar), first pass technique;
single study, at rest or with stress (exercise and/or
pharmacologic), wall motion study plus ejection fraction, with
or without quantification
Code Code Description
78483
Cardiac blood pool imaging, (planar), first pass technique;
multiple studies, at rest and with stress (exercise and/ or
pharmacologic), wall motion study plus ejection fraction, with
or without quantification
78491
Myocardial imaging, positron emission tomography (PET), perfusion
study(including ventricular wall motion[s] and/or ejection fraction[s], when
performed); single study, at rest or stress (exercise or pharmacologic)
78492
Myocardial imaging, positron emission tomography (PET), perfusion
study(including ventricular wall motion[s] and/or ejection fraction[s], when
performed); multiple studies at rest and/or stress (exercise or pharmacologic)
78494
Cardiac blood pool imaging, gated equilibrium, SPECT, at rest,
wall motion study plus ejection fraction, with or without
quantitative processing
78496
Cardiac blood pool imaging, gated equilibrium, single study, at
rest, with right ventricular ejection fraction by first pass
technique (List separately in addition to code for primary
procedure)
78579 Pulmonary ventilation imaging (eg, aerosol or gas)
78580 Pulmonary perfusion imaging, particulate
78582
Pulmonary ventilation (eg, aerosol or gas) and perfusion
imaging
78597
Quantitative differential pulmonary perfusion, including
imaging when performed
78598
Quantitative differential pulmonary perfusion and ventilation
(eg, aerosol or gas), including imaging when performed
78600 Brain imaging, less than 4 static views;
78601 Brain imaging, less than 4 static views; with vascular flow
78605 Brain imaging, minimum 4 static views;
78606 Brain imaging, minimum 4 static views; with vascular flow
78608
Brain imaging, positron emission tomography (PET); metabolic
evaluation
78609
Brain imaging, positron emission tomography (PET); perfusion
evaluation
78610 Brain imaging, vascular flow only
78630
Cerebrospinal fluid flow, imaging (not including introduction of
material); cisternography
78635
Cerebrospinal fluid flow, imaging (not including introduction of
material); ventriculography
78645
Cerebrospinal fluid flow, imaging (not including introduction of
material); shunt evaluation
78650 Cerebrospinal fluid leakage detection and localization
78660 Radiopharmaceutical dacryocystography
78700 Kidney imaging morphology;
78701 Kidney imaging morphology; with vascular flow
Code Code Description
78707
Kidney imaging morphology; with vascular flow and function,
single study without pharmacological intervention
78708
Kidney imaging morphology; with vascular flow and function,
single study, with pharmacological intervention (eg,
angiotensin converting enzyme inhibitor and/or diuretic)
78709
Kidney imaging morphology; with vascular flow and function,
multiple studies, with and without pharmacological
intervention (eg, angiotensin converting enzyme inhibitor
and/or diuretic)
78725 Kidney function study, non-imaging radioisotopic study
78730
Urinary bladder residual study (List separately in addition to
code for primary procedure)
78740
Ureteral reflux study (radiopharmaceutical voiding cystogram)
78761 Testicular imaging with vascular flow
78800
Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, single limited area (includes vascular flow and blood
pool imaging, when performed); planar, single (includes vascular flow and blood
pool imaging, when performed); planar, single
78801
Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, 2 or more mulitple areas (eg, abdomen and pelvis,
head and chest), 1 or more days imaging or single area imaging over 2 or more
days
78802
Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, whole body, single day imaging
78803
Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); tomographic (SPECT) , single area (eg, head, neck, chest,
pelvis), single day imaging
78804
Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, whole body, requiring 2 or more days imaging
78811
Positron emission tomography (PET) imaging; limited area (eg,
chest, head/neck)
78812
Positron emission tomography (PET) imaging; skull base to mid-
thigh
78813 Positron emission tomography (PET) imaging; whole body
78814
Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; limited area
(eg, chest, head/neck)
Code Code Description
78815
Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; skull base to
mid-thigh
78816
Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; whole body
78830 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); tomographic (SPECT) with concurrently acquired
computed tomography (CT) transmission scan for anatomical
review, localization and determination/detection of pathology,
single area (eg, head, neck, chest, pelvis), single day imaging
78831 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); tomographic (SPECT), minimum 2 areas (eg, pelvis
and knees, abdomen and pelvis), single day imaging, or single
area imaging over 2 or more days
78832 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); tomographic (SPECT) with concurrently acquired
computed tomography (CT) transmission scan for anatomical
review, localization and determination/detection of pathology,
minimum 2 areas (eg, pelvis and knees, abdomen and pelvis),
single day imaging, or single area imaging over 2 or more days
93303
Transthoracic echocardiography for congenital cardiac
anomalies; complete
93304
Transthoracic echocardiography for congenital cardiac
anomalies; follow-up or limited study
93306
Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, complete, with spectral Doppler echocardiography,
and with color flow Doppler echocardiography
93307
Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, complete, without spectral or color Doppler
echocardiography
93308
Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, follow-up or limited study
93313 Echocardiography, transesophageal, placement of probe
93314 Echocardiography, transesophageal, image acquisition
93315 Transesophageal, echocardiography
93316 Transesophageal, echocardiography, placement of probe
93317 Transesophageal, echocardiography, image acquistion
93350
Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation
93351
Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation
93452
LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION, WHEN PERFORMED
93453
COMBINED RIGHT AND LEFT HEART CATHETERIZATION
INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT
VENTRICULOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION, WHEN PERFORMED
93356 Myocardial strain imaging using speckle tracking-derived
assessment of myocardial mechanics (List separately in addition
to codes for echocardiography imaging)
Code Code Description
93454
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION;
93455
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH CATHETER
PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY,
FREE ARTERIAL VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY
93456
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT HEART
CATHETERIZATION
93457
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH CATHETER
PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY,
FREE ARTERIAL, VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY AND RIGHT HEART CATHETERIZATION
93458
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED
93459
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S)
(INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS)
WITH BYPASS GRAFT ANGIOGRAPHY
Code Code Description
93460
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT
HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED
93461
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT
HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S)
(INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS)
WITH BYPASS GRAFT ANGIOGRAPHY
93462
Left heart catheterization by trans septal puncture through
intact septum or by trans apical puncture (List separately in
addition to code for primary procedure)
C8900 Magnetic resonance angiography with contrast, abdomen
C8901
Magnetic resonance angiography without contrast, abdomen
C8902
Magnetic resonance angiography without contrast followed by
with contrast, abdomen
C8903 Magnetic resonance imaging with contrast, breast; unilateral
C8905
Magnetic resonance imaging without contrast followed by with
contrast, breast; unilateral
C8906 Magnetic resonance imaging with contrast, breast; bilateral
C8908
Magnetic resonance imaging without contrast followed by with
contrast, breast; bilateral
C8909
Magnetic resonance angiography with contrast, chest
(excluding myocardium)
C8910
Magnetic resonance angiography without contrast, chest
(excluding myocardium)
C8911
Magnetic resonance angiography without contrast followed by
with contrast, chest (excluding myocardium)
C8912
Magnetic resonance angiography with contrast, lower
extremity
C8913
Magnetic resonance angiography without contrast, lower
extremity
C8914
Magnetic resonance angiography without contrast followed by
with contrast, lower extremity
C8918 Magnetic resonance angiography with contrast, pelvis
C8919 Magnetic resonance angiography without contrast, pelvis
Code Code Description
C8920
Magnetic resonance angiography without contrast followed by
with contrast, pelvis
C8931
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST,
SPINAL CANAL AND CONTENTS (crosswalk to 72159)
C8932
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST,
SPINAL CANAL AND CONTENTS (crosswalk to 72159)
C8933
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND
CONTENTS (crosswalk to 72159)
C8934
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST,
UPPER EXTREMITY (crosswalk to 73225)
C8935
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST,
UPPER EXTREMITY (crosswalk to 73225)
C8936
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalk
to 73225)
G0219
PET imaging whole body; melanoma for non-covered
indications
G0235 PET imaging, any site, not otherwise specified
G0252
PET imaging, full and partial-ring pet scanners only, for initial
diagnosis of breast cancer and/or surgical planning for breast
cancer (e.g., initial staging of axillary lymph nodes)
S8037 Magnetic resonance cholangiopancreatography (mrcp)
S8042 Magnetic resonance imaging (MRI), low-field
S8085
Fluorine-18 fluorodeoxyglucose (f-18 fdg) imaging using dual-
head coincidence detection system (non-dedicated pet scan)
Horizon NJ Medicaid and FIDE-SNP
Radiation Therapy Code List
Code Code Description
19294
Preparation of tumor cavity, with placement of
radiation therapy applicator for intraoperative
radiation therapy (IORT), concurrent with partial
mastectomy
19296
Placement of radiotherapy afterloading
expandable catheter (single or multichannel)
into the breast for interstitial radioelement
application following partial mastectomy,
includes imaging guidance; on date separate
from partial mastectomy
19297
Placement of radiotherapy afterloading
expandable catheter (single or multichannel)
into the breast for interstitial radioelement
application following partial mastectomy,
includes imaging guidance; concurrent with
partial mastectomy (List separately in addition
to code for primary procedure)
19298
Placement of radiotherapy after loading
brachytherapy catheters (multiple tube and
button type) into the breast for interstitial
radioelement application following (at the time
of or subsequent to) partial mastectomy,
includes imaging guidance
31643
Bronchoscopy, rigid or flexible, including
fluoroscopic guidance, when performed; with
placement of catheter(s) for intracavitary
radioelement application
32553
Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,
dosimeter), percutaneous, intra-thoracic, single
or multiple
41019
Placement of needles, catheters, or other
device(s) into the head and/or neck region
(percutaneous, transoral, or transnasal) for
subsequent interstitial radioelement application
49411
Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,
dosimeter), percutaneous, intra-abdominal,
intra-pelvic (except prostate), and/or
retroperitoneum, single or multiple
Code Code Description
49412
Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,
dosimeter), open, intra-abdominal, intrapelvic,
and/or retroperitoneum, including image
guidance, if performed, single or multiple (List
separately in addition to code for primary
procedure)
55875
Transperineal placement of needles or catheters
into prostate for interstitial radioelement
application, with or without cystoscopy
55876
Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,
dosimeter), prostate (via needle, any approach),
single or multiple
55920
Placement of needles or catheters into pelvic
organs and/or genitalia (except prostate) for
subsequent interstitial radioelement application
57155
Insertion of uterine tandem and/or vaginal
ovoids for clinical brachytherapy
57156
Insertion of a vaginal radiation afterloading
apparatus for clinical brachytherapy
58346
Insertion of Heyman capsules for clinical
brachytherapy
61796
Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); 1
simple cranial lesion
61797
Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); each
additional cranial lesion, simple (List separately
in addition to code for primary
procedure)
61798
Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); 1
complex cranial lesion
61799
Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); each
additional cranial lesion, complex (List
separately in addition to code for primary
procedure)
61800
Application of stereotactic headframe for
stereotactic radiosurgery (List separately
in addition to code for primary procedure)
Code Code Description
76873
Ultrasound, transrectal; prostate volume study
for brachytherapy treatment planning (separate
procedure)
76965
Ultrasonic guidance for interstitial radioelement
application
77014
Computed tomography guidance for placement
of radiation therapy fields
77261
Therapeutic radiology treatment planning;
simple
77262
Therapeutic radiology treatment planning;
intermediate
77263
Therapeutic radiology treatment planning;
complex
77280
Therapeutic radiology simulation-aided field
setting; simple
77285
Therapeutic radiology simulation-aided field
setting; intermediate
77290
Therapeutic radiology simulation-aided field
setting; complex
77293
Respiratory motion management simulation
(List separately in addition to code for primary
procedure)
77295
3-dimensional radiotherapy plan, including dose-
volume histograms
77300
Basic radiation dosimetry calculation, central
axis depth dose calculation, TDF, NSD, gap
calculation, off axis factor, tissue inhomogeneity
factors, calculation of non-ionizing radiation
surface and depth dose, as required during
course of treatment, onl
77301
Intensity modulated radiotherapy plan, including
dose-volume histograms for target and critical
structure partial tolerance specifications
77306
Teletherapy isodose plan; simple (1 or 2
unmodified ports directed to a single area of
interest), includes basic dosimetry calculation(s)
77307
Teletherapy isodose plan; complex (multiple
treatment areas, tangential ports, the use of
wedges, blocking, rotational beam, or special
beam considerations), includes basic dosimetry
calculation(s)
Code Code Description
77316
Brachytherapy isodose plan; simple
(calculation[s] made from 1 to 4 sources, or
remote afterloading brachytherapy, 1 channel),
includes basic dosimetry calculation(s)
77317
Brachytherapy isodose plan; intermediate
(calculation[s] made from 5 to 10 sources, or
remote afterloading brachytherapy, 2-12
channels), includes basic dosimetry
calculation(s)
77318
Brachytherapy isodose plan; complex
(calculation[s] made from over 10 sources, or
remote afterloading brachytherapy, over 12
channels), includes basic dosimetry
calculation(s)
77321
Special teletherapy port plan, particles,
hemibody, total body
77331
Special dosimetry (eg, TLD, microdosimetry)
(specify), only when prescribed by the treating
physician
77332
Treatment devices, design and construction;
simple (simple block, simple bolus)
77333
Treatment devices, design and construction;
intermediate (multiple blocks, stents, bite
blocks, special bolus)
77334
Treatment devices, design and construction;
complex (irregular blocks, special shields,
compensators, wedges, molds or casts)
77336
Continuing medical physics consultation,
including assessment of treatment parameters,
quality assurance of dose delivery, and review
of patient treatment documentation in support
of the radiation oncologist, reported per week
of therapy
77338
Multi-leaf collimator (MLC) device(s) for
intensity modulated radiation therapy (IMRT),
design and construction per IMRT plan
77370 Special medical radiation physics consultation
77371
Radiation treatment delivery, stereotactic
radiosurgery (SRS), complete course of
treatment of cranial lesion(s) consisting of 1
session; multi-source Cobalt 60 based
77372
Radiation treatment delivery, stereotactic
radiosurgery (SRS), complete course of
treatment of cranial lesion(s) consisting of 1
session; linear accelerator based
Code Code Description
77373
Stereotactic body radiation therapy, treatment
delivery, per fraction to 1 or more lesions,
including image guidance, entire course not to
exceed 5 fractions
77385
Intensity modulated radiation treatment
delivery (IMRT), includes guidance and tracking,
when performed; simple
77386
Intensity modulated radiation treatment
delivery (IMRT), includes guidance and tracking,
when performed; complex
77387
Guidance for localization of target volume for
delivery of radiation treatment, includes
intrafraction tracking, when performed
77399
Unlisted procedure, medical radiation physics,
dosimetry and treatment devices, and special
services
77401
Radiation treatment delivery, superficial and/or
ortho voltage, per day
77402 Radiation treatment delivery, >1 MeV; simple
77407
Radiation treatment delivery; two separate
treatment areas; three or more ports on a single
treatment area; or three or more simple
blocks;>=1 MeV; intermediate
77412
Radiation treatment delivery; three or more
separate treatment areas; custom blocking;
tangential ports; wedges; rotational beam; field-
in-field or other tissue compensation that does
not meet IMRT guidelines; or electron beam;
>=1 MeV; complex
77417 Therapeutic radiology port image(s)
77423
High energy neutron radiation treatment
delivery; 1 or more isocenter(s) with coplanar or
non-coplanar geometry with blocking and/or
wedge, and/or compensator(s)
77424
Intraoperative radiation treatment delivery, x-
ray, single treatment session
77425
Intraoperative radiation treatment delivery,
electrons, single treatment session
77427
Radiation treatment management, 5 treatments
77431
Radiation therapy management with complete
course of therapy consisting of 1 or 2 fractions
only
77432
Stereotactic radiation treatment management
of cranial lesion(s) (complete course of
treatment consisting of 1 session)
Code Code Description
77435
Stereotactic body radiation therapy, treatment
management, per treatment course, to 1 or
more lesions, including image guidance, entire
course not to exceed 5 fractions
77469
Intraoperative radiation treatment management
77470
Special treatment procedure (eg, total body
irradiation, hemibody radiation, per oral or
endocavitary irradiation)
77499
Unlisted procedure, therapeutic radiology
treatment management
77520
Proton treatment delivery; simple, without
compensation
77522
Proton treatment delivery; simple, with
compensation
77523 Proton treatment delivery; intermediate
77525 Proton treatment delivery; complex
77600
Hyperthermia, externally generated; superficial
(ie, heating to a depth of 4 cm or less)
77605
Hyperthermia, externally generated; deep (ie,
heating to depths greater than 4 cm)
77610
Hyperthermia generated by interstitial probe(s);
5 or fewer interstitial applicators
77615
Hyperthermia generated by interstitial probe(s);
more than 5 interstitial applicators
77620
Hyperthermia generated by intracavitary
probe(s)
77750
Infusion or instillation of radioelement solution
(includes 3-month follow-up care)
77761
Intracavitary radiation source application;
simple
77762
Intracavitary radiation source application;
intermediate
77763
Intracavitary radiation source application;
complex
77767
HDR radionuclide skin surface brachytherapy;
lesion diameter up to 2.0 cm or 1 channel
77768
HDR radionuclide skin surface brachytherapy;
lesion diameter over 2.0 cm and 2 or more
channels, or multiple lesions
77770
HDR radionuclide interstitial or intracavitary
brachytherapy; 1 channel
77771
HDR radionuclide rate interstitial or
intracavitary brachytherapy; 2 to 12 channels
Code Code Description
77772
HDR radionuclide interstitial or intracavitary
brachytherapy; over 12 channels
77778
Interstitial radiation source application,
complex, includes supervision, handling, loading
of radiation source when performed
77789
Surface application of low dose rate
radionuclide source
77790
Supervision, handling, loading of radiation
source
77799 Unlisted procedure, clinical brachytherapy
79005
Radiopharmaceutical therapy, by oral
administration; used for I-131 treatment
79101
Radiopharmaceutical therapy, by intravenous
administration
79403
Radiopharmaceutical therapy, radiolabeled
monoclonal antibody by intravenous
infusion
0394T
HDR electronic brachytherapy, skin surface
application, per fraction
0395T
HDR electronic brachytherapy, interstitial or
intracavitary treatment, per fraction
A9606
Radium ra-223 dichloride, therapeutic, per
microcurie (Xofigo)
C2616
Brachytherapy source, nonstranded, yttrium-90,
per source
G0339
Image guided robotic linear accelerator-based
stereotactic radiosurgery, complete course of
therapy in one session or first session of
fractionated treatment
G0340
Image guided robotic linear accelerator-based
stereotactic radiosurgery, delivery including
collimator changes and custom plugging,
fractionated treatment, all lesions, per session,
second through fifth sessions, maximum 5
sessions per course of treatment
G6001
Ultrasonic guidance for placement of radiation
therapy fields
G6002
Stereoscopic x-ray guidance for localization of
target volume for the delivery of radiation
therapy
G6003
Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,
simple blocks or no blocks: up to 5mev
Code Code Description
G6004
Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,
simple blocks or no blocks: 6-10mev
G6005
Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,
simple blocks or no blocks: 11-19mev
G6006
Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,
simple blocks or no blocks: 20mev or greater
G6007
Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: up to
5mev
G6008
Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 6-10mev
G6009
Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 11-
19mev
G6010
Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 20 mev
or greater
G6011
Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; up to 5mev
G6012
Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; 6-10mev
G6013
Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; 11-19mev
G6014
Radiation treatment delivery,3 or more separate
treatment areas, custom blocking, tangential
ports, wedges, rotational beam, compensators,
electron beam; 20mev or greater
G6015
Intensity modulated treatment delivery, single
or multiple fields/arcs,via narrow spatially and
temporally modulated beams, binary, dynamic
mlc, per treatment session
Code Code Description
G6016
Compensator-based beam modulation
treatment delivery of inverse planned treatment
using 3 or more high resolution (milled or cast)
compensator, convergent beam modulated
fields, per treatment session
G6017
Intra-fraction localization and tracking of target
or patient motion during delivery of radiation
therapy (eg, 3d positional tracking, gating, 3d
surface tracking), each fraction of treatment